European Resuscitation Council Guidelines for Resuscitation 2010 ...

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1318 C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 The tubes are sized in millimetres according to their internal diameter, and the length increases with diameter. The traditional methods of sizing a nasopharyngeal airway (measurement against the patient’s little finger or anterior nares) do not correlate with the airway anatomy and are unreliable. 326 Sizes of 6–7 mm are suitable for adults. Insertion can cause damage to the mucosal lining of the nasal airway, resulting in bleeding in up to 30% of cases. 327 If the tube is too long it may stimulate the laryngeal or glossopharyngeal reflexes to produce laryngospasm or vomiting. Oxygen During CPR, give oxygen whenever it is available. There are no data to indicate the optimal arterial blood oxygen saturation (SaO 2 ) during CPR. There are animal data 328 and some observational clinical data indicating an association between high SaO 2 after ROSC and worse outcome. 329 A standard oxygen mask will deliver up to 50% oxygen concentration, providing the flow of oxygen is high enough. A mask with a reservoir bag (non-rebreathing mask), can deliver an inspired oxygen concentration of 85% at flows of 10–15 l min −1 . Initially, give the highest possible oxygen concentration. As soon as the arterial blood oxygen saturation can be measured reliably, by pulse oximeter (SpO 2 ) or arterial blood gas analysis, titrate the inspired oxygen concentration to achieve an arterial blood oxygen saturation in the range of 94–98%. Suction Use a wide-bore rigid sucker (Yankauer) to remove liquid (blood, saliva and gastric contents) from the upper airway. Use the sucker cautiously if the patient has an intact gag reflex; pharyngeal stimulation can provoke vomiting. Ventilation Provide artificial ventilation as soon as possible for any patient in whom spontaneous ventilation is inadequate or absent. Expired air ventilation (rescue breathing) is effective, but the rescuer’s expired oxygen concentration is only 16–17%, so it must be replaced as soon as possible by ventilation with oxygen-enriched air. The pocket resuscitation mask is used widely. It is similar to an anaesthetic facemask, and enables mouth-to-mask ventilation. It has a unidirectional valve, which directs the patient’s expired air away from the rescuer. The mask is transparent so that vomit or blood from the patient can be seen. Some masks have a connector for the addition of oxygen. When using masks without a connector, supplemental oxygen can be given by placing the tubing underneath one side and ensuring an adequate seal. Use a two-hand technique to maximise the seal with the patient’s face (Fig. 4.6). High airway pressures can be generated if the tidal volume or inspiratory flow is excessive, predisposing to gastric inflation and subsequent risk of regurgitation and pulmonary aspiration. The possibility of gastric inflation is increased by: • malalignment of the head and neck, and an obstructed airway; • an incompetent oesophageal sphincter (present in all patients with cardiac arrest); • a high airway inflation pressure. Conversely, if inspiratory flow is too low, inspiratory time will be prolonged and the time available to give chest compressions is reduced. Deliver each breath over approximately 1 s and transfer a volume that corresponds to normal chest movement; this represents a compromise between giving an adequate volume, minimising the risk of gastric inflation, and allowing adequate time for chest compressions. During CPR with an unprotected airway, Fig. 4.6. Mouth-to-mask ventilation. give two ventilations after each sequence of 30 chest compressions. Self-inflating bag The self-inflating bag can be connected to a facemask, tracheal tube or supraglottic airway device (SAD). Without supplemental oxygen, the self-inflating bag ventilates the patient’s lungs with ambient air (21% oxygen). The delivered oxygen concentration can be increased to about 85% by using a reservoir system and attaching oxygen at a flow 10 l min −1 . Although the bag-mask device enables ventilation with high concentrations of oxygen, its use by a single person requires considerable skill. When used with a face mask, it is often difficult to achieve a gas-tight seal between the mask and the patient’s face, and to maintain a patent airway with one hand while squeezing the bag with the other. 330 Any significant leak will cause hypoventilation and, if the airway is not patent, gas may be forced into the stomach. 331,332 This will reduce ventilation further and greatly increase the risk of regurgitation and aspiration. 333 Cricoid pressure can reduce this risk 334,335 but requires the presence of a trained assistant. Poorly applied cricoid pressure may make it more difficult to ventilate the patient’s lungs. 334,336–339 The two-person technique for bag-mask ventilation is preferable (Fig. 4.7). One person holds the facemask in place using a jaw thrust with both hands, and an assistant squeezes the bag. In this way, a better seal can be achieved and the patient’s lungs can be ventilated more effectively and safely. Once a tracheal tube or a supraglottic airway device has been inserted, ventilate the lungs at a rate of 10 breaths min −1 and continue chest compressions without pausing during ventilations. The laryngeal seal achieved with a supraglottic airway device is unlikely to be good enough to prevent at least some gas leaking when inspiration coincides with chest compressions. Moderate gas leakage is acceptable, particularly as most of this gas will pass up through the patient’s mouth. If excessive gas leakage results in inadequate ventilation of the patient’s lungs, chest compressions will have to be
C.D. Deakin et al. / Resuscitation 81 (2010) 1305–1352 1319 A manikin study of simulated cardiac arrest and a study involving fire-fighters ventilating the lungs of anaesthetised patients both showed a significant decrease in gastric inflation with manuallytriggered flow-limited oxygen-powered resuscitators and mask compared with a bag-mask. 345,346 However, the effect of automatic resuscitators on gastric inflation in humans in cardiac arrest has not been studied, and there are no data demonstrating clear benefit over bag-valve-mask devices. Passive oxygen delivery Fig. 4.7. The two-person technique for bag-mask ventilation. interrupted to enable ventilation, using a compression-ventilation ratio of 30:2. Automatic ventilators Very few studies address specific aspects of ventilation during advanced life support. There is some data indicating that the ventilation rates delivered by healthcare personnel during cardiac arrest are excessive, 242,340,341 although other studies have shown more normal ventilation rates. 245,342,343 Automatic ventilators or resuscitators provide a constant flow of gas to the patient during inspiration; the volume delivered is dependent on the inspiratory time (a longer time provides a greater tidal volume). Because pressure in the airway rises during inspiration, these devices are often pressure limited to protect the lungs against barotrauma. An automatic ventilator can be used with either a facemask or other airway device (e.g., tracheal tube, supraglottic airway device). An automatic resuscitator should be set initially to deliver a tidal volume of 6–7 ml kg −1 at 10 breaths min −1 . Some ventilators have coordinated markings on the controls to facilitate easy and rapid adjustment for patients of different sizes, and others are capable of sophisticated variation in respiratory parameters. In the presence of a spontaneous circulation, the correct setting will be determined by analysis of the patient’s arterial blood gases. Automatic resuscitators provide many advantages over alternative methods of ventilation. • In unintubated patients, the rescuer has both hands free for mask and airway alignment. • Cricoid pressure can be applied with one hand while the other seals the mask on the face. • In intubated patients they free the rescuer for other tasks. 344 • Once set, they provide a constant tidal volume, respiratory rate and minute ventilation; thus, they may help to avoid excessive ventilation. • Are associated with lower peak airway pressures than manual ventilation, which reduces intrathoracic pressure and facilitates improved venous return and subsequent cardiac output. In the presence of a patent airway, chest compressions alone may result in some ventilation of the lungs. 347 Oxygen can be delivered passively, either via an adapted tracheal tube (Boussignac tube), 348,349 or with the combination of an oropharyngeal airway and standard oxygen mask with non-rebreather reservoir. 350 Although one study has shown higher neurologically intact survival with passive oxygen delivery (oral airway and oxygen mask) compared with bag-mask ventilation after out-of-hospital VF cardiac arrest, this was a retrospective analysis and is subject to numerous confounders. 350 There is insufficient evidence to support or refute the use of passive oxygen delivery during CPR to improve outcome when compared with oxygen delivery by positive pressure ventilation. Until further data are available, passive oxygen delivery without ventilation is not recommended for routine use during CPR. Alternative airway devices The tracheal tube has generally been considered the optimal method of managing the airway during cardiac arrest. There is evidence that, without adequate training and experience, the incidence of complications, such as unrecognised oesophageal intubation (6–17% in several studies involving paramedics) 351–354 and dislodgement, is unacceptably high. 355 Prolonged attempts at tracheal intubation are harmful; the cessation of chest compressions during this time will compromise coronary and cerebral perfusion. Several alternative airway devices have been considered for airway management during CPR. There are published studies on the use during CPR of the Combitube, the classic laryngeal mask airway (cLMA), the laryngeal tube (LT) and the I-gel, but none of these studies have been powered adequately to enable survival to be studied as a primary endpoint; instead, most researchers have studied insertion and ventilation success rates. The supraglottic airway devices (SADs) are easier to insert than a tracheal tube and, unlike tracheal intubation, can generally be inserted without interrupting chest compressions. 356 There are no data supporting the routine use of any specific approach to airway management during cardiac arrest. The best technique is dependent on the precise circumstances of the cardiac arrest and the competence of the rescuer. Laryngeal mask airway (LMA) The laryngeal mask airway (Fig. 4.8) is quicker and easier to insert than a tracheal tube. 357–364 The original LMA (cLMA), which is reusable, has been studied during CPR, but none of these studies has compared it directly with the tracheal tube. A wide variety of single-use LMAs are used for CPR, but they have different characteristics to the cLMA and there are no published data on their performance in this setting. 365 Reported rates of successful ventilation during CPR with the LMA are very high for in-hospital studies (86–100%) 366–369 but generally less impressive (71–90%) 370–372 for out-of-hospital cardiac arrest (OHCA). The reason for the relatively disappointing results from the LMA in OHCA is not clear.
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